Wiki Need help with surgery billing


Richmond, TX
Best answers
I work with a plastic surgeon. He is supposed to do a surgery but is not in network with the patient's plan. The patient's plan might have OON benefits but to avoid all the complications of the NSA act and then the Insurance pays too little. He is going to do it as self pay and the patient has agreed to it. But the Hospital will bill the Insurance for the ancillaries. I just wanna make sure if the facility bills the Ins. then the doctor is supposed to bill the Ins. too? The patient can't afford to pay for the hospital charges.
Someone told me that it happened to them and the Insurance came back and recouped the facility.

I would appreciate anyone with a response.
Is the procedure being performed, as well as the diagnosis/condition, by your surgeon covered by the patient's insurance policy/plan? In the case that "someone" told you about was the procedure performed and the diagnosis/condition covered by that patient's policy/plan?

Without a bit more background it is hard to say if there will be an issue for your patient's hospital claim will be covered. Also, for the patient you were told about that had their hospital claim payment recouped it is hard to say if it could happen to your patient without knowing the procedure and diagnosis/condition that patient was receiving treatment for.

Also, not all insurance plans are created the same. So, your patient's plan may cover services that the other patient's plan. The hospital claim for the other patient could have been reviewed as a post-payment claim review and it was determined that the service(s) or condition weren't covered, and it wasn't caught at the time the claim was initially processed.

I have worked in the health insurance industry for 20+ years and can think of so many reasons why your patient's hospital claim may or may not be covered, as well as why the other patient's claim was adjusted to recoup the previous payment.

If you want to share more info, I would be happy to try and help you figure out what might happen for your patient's hospital claim. In addition to knowing the procedure(s) and diagnosis/condition being treated it would be helpful to know who the insurance company is, what the name of the plan is and what state their insurance is issued in.
This is very dependent on the patient's plan. Many insurances will not pay the facility if the surgery itself is not covered under the plan. If the patient does in fact have OON benefits, then the surgery is covered (just perhaps applied to deductible for example), then it would be less of a concern.
The payor should be able to answer this for you.
PS - PLEASE avoid duplicate postings
Thank you for your replies. The patient's plan is Cigna and it's in Texas. The procedure is covered by the plan but we are not in network and the Ins. will definitely apply the No surprise act because the Hospital is in INN and we won't be able to apply the non par rate or maybe negotiate. Therefore we want to do the self pay.